Is there a relationship between codependency and ADHD?

Published on November 29, 2012

Introduction

Codependency and adult attention deficit hyperactivity are special areas of clinical interest for me. Over the past couple of years, I had begun to notice that clients who initially had come for codependency treatment, frequently exhibited symptoms of ADHD. It also seemed that clients in therapy for ADHD commonly reported rather adverse childhoods e.g. divorce of parents. These observations prompted me to think about a possible connection between codependency and ADHD.

Codependency refers to emotional and psychological problems experienced by adults who were subjected to abuse/neglect in childhood (Mellody, 1989). Other designations for what seems identical to codependency are “complex PTSD” (Herman, 1992) and developmental trauma disorder (van der Kolk, 2005).

Although none of these terms are officially recognized in the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association, there has been an effort by some mental health professionals to have complex PTSD officially recognized and included in the next edition of the DSM (Herman, 2012; van der Kolk, 2005; Wylie, 2010).

Here, the term codependency is meant to include complex PTSD and developmental trauma. What is certain is that research over the past several decades has increasingly provided convincing and abundant scientific evidence for an association between child traumatization and a variety of adult psychiatric problems.

ADHD is a well recognized disorder characterized by attentional and memory problems and / or high levels of motor activity and impulsivity. ADHD is generally assumed to be a neurodevelopmental disorder and according to the DSM must include at least some symptoms of impaired function before the age of 7. What specifically causes ADHD is not fully understood or agreed upon at the present time and no reference could be found in the literature associating it with childhood trauma or adversity.

Since codependency by definition involves having been exposed to child abuse, it follows that if there was evidence for an association between child abuse, neglect or adversity and ADHD, that would support and explain my clinical observation of an apparent association between codependency and ADHD. The purpose of this post is to present evidence of such an association and its clinical implications.

Scientific evidence for an association between childhood adversity and adult ADHD

A brief review of the scientific literature for evidence linking childhood adversity including child abuse or other forms of traumatization and ADHD was carried out. Two studies were found which provided substantial evidence for an increased prevalence of ADHD in persons who had been abused or maltreated as children (Sugaya et al, 2012; Kocovska et al, 2012).

The Sugaya study

The Sugaya study surveyed 43,093 US adults and found a highly significant increase in the prevalence of ADHD in those who reported having experienced physical abuse in childhood compared to those who did not report child physical abuse. Specifically these researchers found that in those who did not report child physical abuse, only 1.90% developed ADHD.

In contrast, in those who reported child physical abuse, the presence of ADHD jumped to 9.35%. This is an increase of almost five fold and was highly significant statistically even when corrections made for certain possible confounding factors. Hence these results strongly support the hypothesis of an association between child physical abuse and ADHD.

The Sugaya study is significant because of its relatively huge sample size: it is by far the largest survey ever to investigate the association between abuse in childhood and adult psychiatric problems. One limitation was that the reports of childhood abuse were retrospective and as such were open to the effects of subjectivity.

The Kocovska study

Kocovska et al in a much smaller study, involving only 66 children, also found evidence of increased presence of ADHD study in adopted children “with symptoms of indiscriminate friendliness and a history of severe maltreatment” (Kocovska et al, 2012). Specifically, 50% of the 34 maltreated children had ADHD while none of the 32 children in their control group of non-maltreated children had ADHD.

The prevalence of ADHD was only 9.35% in Sugaya study compared to the whopping 50% reported in the Kocovska study. This was probably due to the fact that in the Kocovska study the term “maltreated” children would have included a greater variety of types of abuse. In contrast the Sugaya study restricted itself to childhood physical abuse.

Conclusions, implications, and an important caveat

There is significant scientific evidence for an association between childhood adversity and ADHD

The results of the Sugaya and Kocovska studies provide for the first time quite strong evidence for an association between childhood adversity (including child physical abuse and more general maltreatment) and ADHD. Since codependency by definition is associated with child abuse and the Sugaya and Kocovska studies show child abuse is associated with ADHD, then it follows that codependency and ADHD are also associated.

Caveat: Correlation does not prove causation and evidence that even if child abuse is a causative factor, it is not the main one. The results of the two studies reported here are correlational and as such cannot prove causality although they may be suggestive of it. Hence these results do not imply that child abuse directly causes ADHD.

For example it may be that children with ADHD are more stressful to parent than neurotypicals children and hence predisposed to child abuse. Moreover these results do not imply that all cases of adult ADHD are associated with child abuse. In fact, the Sugaya study provided evidence that child physical abuse is not the main factor associated with adult ADHD. Since the total number of adults with ADHD in this survey numbered approximately 884, then only 290 out of 884, or about one in three cases of ADHD reported child physical abuse. In other words, two thirds of the cases of adult ADHD did not report child physical abuse.

Clinical implications for prevention and treatment of codependency and ADHD

The confirmation of my clinical observation of a link between codependency and ADHD by the results of the Sugaya and Kocovska research has important clinical implications. This suggests that it would be reasonable to screen clients with codependency for ADHD as well. The reason is simple: without amelioration of the various problems associated with ADHD, it would be difficult to treat the co-existing codependency.

More specifically, the likely poor mental concentration, general mental and physical restlessness, and frequent serious addictive behaviour of adult ADHD would make codependency treatment and recovery more difficult.

Similarly, clients with adult ADHD should be assessed for codependency and associated child adversity. If the latter is found then treatment for codependency should follow the primary treatment for ADHD. Only if the client enjoys the emotional relief that accompanies codependency recovery are they likely to follow the behavioural and medication regimens required for successful management of ADHD.

Summary

1. There is convincing research evidence supporting an association between childhood abuse/neglect/maltreatment and ADHD.

2. Because codependency by definition involves childhood abuse maltreatment, it logically follows from the above association that there would be an association between codependency and ADHD.

3. The association between codependency and adult ADHD strongly suggests that assessment for ADHD should be routinely carried out in clients presenting with codependency.

4. Similarly assessment for codependency and associated child traumatization should become routine in clients initially presenting for ADHD.

5. If a client has co-existing codependency and ADHD, then it is necessary to address both problems, with the initial emphasis being on ADHD treatment.

Written by:

Brian Scott

Dr. Scott is a clinical psychologist based in Singapore with three decades of counseling and psychotherapy experience in helping adults with many kinds of psychological difficulties. These include anxiety, depression, addictions (cybersex, love), and Adult Attention Deficit Hyperactivity Disorder (Adult ADHD).